Medical Records Director (Health Information Management)

Oakwood Gardens Care Center
Starting Pay: $23.00+/hour (DOE)
Status: Full-Time • On-site
About the Role

The Medical Records Director (HIM) organizes, maintains, and safeguards resident health information in accordance with facility policy, OBRA, HIPAA/Privacy Rules, and state/federal regulations. This role partners closely with Nursing, MDS, and our Health Information/Medical Records Consultant to ensure accurate, timely, and secure documentation.
Key Responsibilities
Medical Records Operations

• Receive/follow schedules and policies; assist with organizing, planning, and directing the department.
• Maintain meeting minutes; file and retrieve records (manual/electronic) and deliver as needed.
• File nurses' notes, assessments, progress notes, labs, X-ray results, correspondence, etc., into resident charts.
• Collect, assemble, check, and file charts; ensure incomplete records are returned for correction.
• Develop procedures to ensure records are completed, coded, signed, indexed, and filed properly.
• Control chart access/exit per policy; maintain log of authorized disclosures (type, recipient, date, department).
• Abstract information for payers (Medicare/Medicaid/VA/insurers) per Privacy Rules.
• Maintain registries (admissions/discharges) and index records as directed.

Coordination & Compliance

• Assist the Medical Records/Health Information Consultant as required.
• Assist MDS Coordinator with scheduling assessments per facility and OBRA guidelines.
• Batch resident information into the EHR; retrieve demographics as instructed.
• Prepare written correspondence; answer medical record inquiries.
• Ensure sign-out/sign-in of charts removed from the department; file active/inactive records per policy.

Committees & Administration

• Perform secretarial duties for committees; assemble records and prepare requested reports.
• Maintain census and report status changes.
• Report suspected fraud or unauthorized system access to the Administrator.

Staff Development & Supervision

• Supervise department staff (including coaching and discipline as appropriate).
• Attend/participate in mandatory in-services (OSHA, TB, HIPAA, Abuse Prevention) and approved workshops.

Safety, Equipment & Supplies

• Report unsafe conditions/equipment malfunctions promptly.
• Maintain clean, organized work areas; ensure adequate supplies.

Other

• Protect system credentials; safeguard resident PHI at all times.
• Support emergency response/evacuation as needed.
• Perform other duties as assigned.

Qualifications

• High school diploma or GED required.
• Typing 45+ WPM; ability to use dictation equipment.
• Working knowledge of medical terminology (anatomy/physiology, coding, indexing, legal aspects) preferred; on-the-job training provided.
• Computer proficient; data retrieval/input/output; EHR experience a plus.
• Strong attention to detail, organization, tact, and teamwork; ability to follow written/oral instructions and make sound independent decisions.

Physical Demands

• Intermittent movement throughout the day; ability to push/pull/move/carry 25 lbs to a height of 5 ft and for 50 ft as needed.
• Adequate vision/hearing (with or without prosthetics) to meet job requirements.
• Ability to manage routine job stressors; maintain integrity, flexibility, and effective collaboration.

Work Environment

• Office and facility settings with frequent interruptions; occasional evenings/weekends/holidays or call-backs during emergencies.
• Potential exposure to infectious waste/air contaminants and hazardous chemicals; adherence to safety protocols required.

Note: Nothing in this description restricts management's right to assign or reassign duties at any time. Duties may change due to reasonable accommodation or operational needs.